Fu Hwai-Hui, Tsai Hsien-Tang, Lin Ching-Wei, Wei Duan
Fortune Institute of Technology at Kaohsiung, Taiwan, Business Administration, 3F-5, 10, ANSHYR Road, Kaohsiung 803, Taiwan.
Health Policy. 2004 Nov;70(2):185-95. doi: 10.1016/j.healthpol.2004.02.006.
National Health Insurance (NHI) has been implemented in Taiwan for nearly a decade. Owing to growing demand for medical-care, effective sampling auditing is a key factor in obtaining reasonably priced medical-care services. This investigation proposes a conceptual framework "medical-claim payment auditing (MCPA) procedure" based on the "Military Standard 105E (MIL-STD-105E) single sampling plan" for establishing an objective criterion for making medical-claim payments fairly. The MCPA procedure contributes to the following: (1) meeting international standards of sampling technology; (2) reducing the sampling ratio and consequently auditing costs; and (3) encouraging healthcare providers to honestly apply their medical-claim payments thus avoid wasting medical resources.
全民健康保险（NHI）在台湾已实施近十年。由于医疗保健需求不断增长，有效的抽样审计是获得价格合理的医疗保健服务的关键因素。本调查基于“军标105E（MIL-STD-105E）单次抽样计划”提出了一个概念框架“医疗索赔支付审计（MCPA）程序”，以建立公平进行医疗索赔支付的客观标准。MCPA程序有助于实现以下几点：（1）符合抽样技术的国际标准；（2）降低抽样率，从而降低审计成本；（3）鼓励医疗服务提供者诚实地申请医疗索赔支付，从而避免浪费医疗资源。
